The original aim of this study was to recruit the last 5 older people who had been admitted to a case manager’s caseload, and who had been on the caseload for no more than 1 year and ideally for 3 months or less. The inclusion criteria for the study (being over 60, expected to live for 9
months, having no severe dementia or mental health problems) posed some challenges when recruiting the sample. The Specialist Nurses found it difficult to identify suitable patients aged over 60 years. Community Matrons were not always able to identify patients expected to survive for 9 months, while district nurses were constrained both by the age and frailty of their patients and the numbers who they could identify as being case managed:
“It’s difficult to find enough patients to fit with your criteria, quite a few of mine tend to be either younger, or if they are older they are too ill, or deteriorating quite quickly”. District Nurse
There was also some ‘gate keeping’ by the nurses based on their
professional values and their experiences. Some would not approach certain patients about the study if they felt the patient was emotionally or
otherwise too fragile to take part or if they were concerned that
participation in the study would damage a nurse/patient relationship that was still in its early stages:
“I have a couple of patients that are new to me, but I am still assessing them and I don’t think it’s the right time to ask them about a study. Both of them are probably too ill anyhow. I wouldn’t want to ask any of my patients
that I think might be worried to say no but not really want to do it –some of them have had a hard time and are quite nervous and frail, sometimes it is was enough for them to accept me into their lives and they have had a lot of contact from all kinds of people as a result. I think the study would be too much for them.” Community Matron
Patients new to a case manager’s caseload often were in the process of encountering a number of other practitioners from a variety of agencies.
Consequently, on a few occasions nurses identified eligible patients but asked that we delay making contact with them so that new faces did not overwhelm them. Another also acknowledged her protectiveness of patients:
”I am very protective of my patients, and there are some it would not be right to ask because they are too frail, or because I am still building their trust in me”. District nurse
Following these filters, 89 patients were approached but of these 12 felt too ill to take part, 9 were not interested in taking part, 9 felt they did not have time and the remaining three gave no reason for declining (Table 30).
Those with insufficient time to take part were primarily patients of specialist nursing services, or those with caring responsibilities.
Table 30. Reasons for not taking part
Following an extended process of recruitment 56 patients agreed to participate in the study. Of the sample of 56, 5 people either died (4) or became too ill (1) to participate during the first month of the study. This meant that 51 patients were participating in the study at baseline (see table 31)
Table 31. Patient and carer recruitment to the sample Approached Consented Withdrawn/RIP
within first month
Remaining at baseline
Patients 89 56 5 51
Carers 15 9 2 7
All of those taking part lived within the PCT area of their respective nurses at the start of the study. One moved to an adjacent area in the course of the nine months, remaining on her nurse’s specialist caseload because there was not an equivalent service in the area. Two patients did not feel well enough to be interviewed during the study but gave permission for their
Lack of time
Health Not interested Not relevant
None given
Total
Patients 9 12 9 3 33
Carers 2 1 3 6
care to be tracked using nursing notes and interviews at the beginning and end of the data collection.
6.2.1 Joining a nurse case manager’s caseload The study aimed to recruit patients as close to the commencement of having a nurse case manager as possible. The samples time on the nurse case managers’ caseload ranged from 1- 22 months. The length of time reflecting the recruitment issues outlined above. The mean time on caseload prior to the study for all patients was 3 months (table 32). The range for Community Matrons was higher than that of other nurses, primarily because the Community Matron in one site had a well-established caseload and had not taken on many eligible new patients in the months prior to the
commencement of the study. Patients who had been on a nurse case manager’s caseload for several months prior to joining the study had an established relationship with their case manager. It might be expected that less change is seen among patients who have been on nurses’ caseloads for the longest periods.
Table 32. Time on nurses caseload prior to joining study
Key: CM = Community Matron, DN= District Nurse, CNS=Community Nurse Specialist, PN=Practice Nurse, CHST = Care Home support team
Patients were referred to a nurse case manager in a variety of ways;
following an admission to hospital or through a medical consultant, from a GP, as a patient of an existing community nursing service or through a process of case finding (table 33).
Referral between nursing services occurred when patients, because of the increasing complexity of their condition or situation, were judged to need more structured assessment and support than they were currently
receiving. It was interesting that many of the community matrons’ patients were referred to them by other community nursing services (typically specialist nursing services). Among district nurses who had a case manager component to their work, there was a relatively high level of referral from the wider district nursing team (54%).
Nurse case manager type Time on case
load prior to joining (months)
CM
(n=21) DN
(n=11) CNS
(n=13) CHST
(n=3) NP (n=3) All types
Mean 4.5 1.5 3 1.7 1.7 3.4
Median 3 1 3 2 2 2
Mode 1 1 1 - - 2
Range 1-22 1-6 1-6 1-2 1-2 1-22
Standard Deviation
5.09 1.37 1.95 0.58 0.58 3.57
Table 33. Referral routes to nurse case managers
Community Nurse Specialists received over half of their patients through secondary care referral. Referrals made from secondary care were
frequently made after an exacerbation leading to hospital admission where the hospital team or specialist considered that intensive support would be needed when the patient returned home. Patients were usually appreciative of this, especially if they had had negative experiences of discharge in the past:
“It made a difference. Before when I came out they sent in a nurse for a few days and it was, well, kind of, nothing. You know? This time it was better, she came to see me almost as soon as I got home and she seems to have been around ever since, and she seems to have helped sort out things I need”. Community Matron Patient
“The consultant told me about the COPD nurses and said that he thought they would help me. He told me about the rehab course and said he’d suggest they put me on it. That’s all I was expecting really, but they have been much more helpful than that. They look after everything, and even helped me with my heart problems and my problems with my GP”. Nurse specialist Patient
Of the 51 patients in the sample, 9 were taken on to a nurse case
management system through active case finding (usually using the Patient At Risk of Readmission PARR tool). Of these, 8 were the patients of
Community Matrons. One nurse specialist used the PARR tool to review cases within her team’s caseload. Patients identified by case finding were
Nurse case manager type Referral route to
‘high intensity’ users who had had 3 or more chronic or long-term
conditions and a minimum of 3 unplanned hospital admissions in the year prior to their identification.
Patients admitted to caseloads often expressed surprise at finding they had been allocated a Community Matron. As ‘high intensity’ service users they tended to be familiar with chains of referral and referral processes. Being approached independently, without a GP or other professional telling them this would be happening, initially worried some patients:
“I don’t really know where she came from. She just phones out of the blue one day, nobody told me she would be getting in touch, and usually that’s what they do. I don’t know someone like the doctor or the heart man tells you they will be putting you in touch with someone. But this time she just appeared.” Community Matron Patient
“I don’t really know how she found out about me, and at first I was worried about that. I thought maybe they wanted to put me in a home or something because she came and asked all these questions and spent so long with me.
Most of them don’t do that, do they?” Community Matron Patient During the course of the study there was a shift in how patients were identified for case managed support and community matrons started to take more referrals from GPs and hospital consultants. The PARR tool was not identifying new patients for their caseloads and using a structured model of this type missed some patients with high intensity needs who had not been admitted to hospital.